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Chronic Care/Chronic Disease Management Models for COPD

Chronic disease management programs addressing COPD may be based on the Chronic Care Model. Components of this model include links to community resources, health system support, and self-management. The structure and delivery of these types of program may vary, but they usually provide information about COPD, offer education about behavior change, and provide information about medication adherence and management. According to the Global Initiative for Chronic Obstructive Lung Disease, self-management education – with coaching by a healthcare professional – should be a component of this model.

Self-management. Based on a definition from a consensus of international experts,

“A COPD self-management intervention is structured but personalized and often multi-component, with goals of motivating, engaging and supporting the patients to positively adapt their health behavior(s) and develop skills to better manage their disease.”

Programs focus on education and behavior change, such as the adoption and maintenance of health-promoting behaviors, and emphasize the patient's role in the active management of their COPD. Self-management change seeks to improve physical and emotional health and quality of life, in addition to minimizing COPD-related impairments. Strong partnerships with healthcare providers, caregivers, and loved ones underpin effective self-management programs, particularly iterative communication to maintain patient motivation and knowledge. These strategies typically originate in clinical settings, but remote connection options are available through computers and mobile devices.

Action Plans. Self-management is particularly effective when patients develop action plans outlining the steps that they will take to implement their strategies. These can be written or oral, based on standard templates or tailored to each patient. This action plan drives patients to move beyond knowledge of their self-management responsibilities and pushes them to think about how they will effectively change their behavior. A 2016 systematic review suggests that the development of COPD action plans is associated with reduced hospitalizations and emergency department visits for COPD exacerbations, compared to patients who received usual care. Action plans can provide enhanced benefits when supplemented by a short educational follow-up that supports patient plan adherence.

Examples of Chronic Care/Chronic Disease Management Program Models

  • Chronic Disease Self-Management is an evidence-based program developed by Stanford University. It consists of a six-week workshop designed for people with multiple chronic conditions including COPD.
  • Genesis HealthCare System's COPD Readmission Prevention Program in Zanesville, Ohio, uses a chronic disease care management approach to improve readmission rates for COPD patients. Through the use of registered nurses serving as both navigators and tobacco treatment specialists, the program is able to offer assistance to COPD patients throughout the continuum of care.
  • The American Lung Association's Better Breathers Club connects people with various lung diseases to resources, support, and education. Activities are led by trained facilitators and are offered nationwide.
  • Bridges to Care Transitions, a collaborative program led by Bay Rivers Telehealth Alliance, offers remote home monitoring and chronic disease management coaching to patients with chronic illnesses in rural Tidewater, Virginia. Patients enroll in the program at the time of discharge from the hospital and participate in up to 90 days of remote home monitoring and coaching. The program incorporates a variety of evidence-based models, including the Coleman model, the Healthy IDEAS model, and Stanford model for Chronic Disease Self-Management.
  • The Adventist Health System Quality Improvement Project, based in rural Butte County, California, offers a variety of COPD services including medication, education, smoking cessation, and infection prevention, including information about recommended vaccines. The project was modeled on the evidence-based Reversible Obstructive Airway Disease (ROAD) program from the University of California Davis Medical Center. COPD patients are provided with treatment planning, case management, and one-on-one education.
  • The Sarah Bush Lincoln Health Center in rural east central Illinois is using evidence-based efforts to improve the quality of life among COPD patients and reduce hospital utilization. Program efforts focus on patient activation, self-management behaviors, and medication management. The program uses motivational interviewing to assist patients with self-management techniques.

Considerations for Implementation

Strong patient-provider relationships with clear communication are critical to successful self-management. Care team members should ensure that they consistently support and encourage patients in their self-management efforts in order to build confidence in their ability to successfully achieve their goals and to hold them accountable to completing their action plans.

COPD is often accompanied by other chronic comorbidities, such as diabetes, heart disease, lung cancer, osteoporosis, and mood disorders. Patients with multiple chronic illnesses and comorbidities receive care from various providers, which can result in disparate and fragmented care strategies. Since many COPD patients present complex needs, chronic care models should seek to streamline various elements to improve quality of life and minimize exacerbations. Successful streamlined care is dependent upon effective collaboration and communication among different care team members and between the care team and the patient.

Program Clearinghouse Examples

Resources to Learn More

Chronic Disease Management in Rural Areas
Document
Case descriptions of six rural health organizations that have implemented chronic disease management programs.
Author(s): Zuniga, M., Bolin, J., & Gamm, L.
Organization(s): Southwest Rural Health Research Center
Date: 2003

COPD Management Tools
Website
Offers a variety of tools helpful with managing COPD, including sample action plan in both English and Spanish for patients to complete with his/her healthcare provider.
Organization(s): American Lung Association

Integrated Disease Management Interventions for Patients with Chronic Obstructive Pulmonary Disease
Document
A literature review of 26 trials evaluating the effects of an integrated disease management (IDM) intervention for people with COPD.
Author(s): Kruis, A., Smidt, N., Assendelft, W., Gussekloo, J., Boland, M., Rutten-van Molken, M., & Chavannes, N.
Citation: Cochrane Database of Systematic Reviews, Issue 10
Date: 10/2013

Offering Chronic Disease Self-Management Education in Rural Areas
Document
Provides recommendations and resources for implementing chronic disease self-management education programs in rural settings and includes success stories.
Organization(s): National Council on Aging
Date: 7/2015